Use of primary care services by elderly people with chronic conditions, Brazil

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1 Mri Aprecid P Rodrigues I,II Luiz Augusto Fcchini I Roberto Xvier Piccini I Eline Tomsi III,IV Use of primry cre services by elderly people with chronic conditions, Brzil Eline Thumé I,V Denise Silv Silveir I,III Fernndo Vinholes Siqueir IV Ver Mri Vieir Pniz I I Deprtmento de Medicin Socil. Fculdde de Medicin. Universidde Federl de Pelots (UFPel). Pelots, RS, Brsil II Secretri Estdul de Súde do Rio Grnde do Sul. Porto Alegre, RS, Brsil III Secretri Municipl de Súde e Bem Estr de Pelots. Pelots, RS, Brsil IV Centro de Ciêncis Humns e d Educção, Escol de Psicologi. Universidde Ctólic de Pelots. Pelots, RS, Brsil V Deprtmento de Enfermgem, Fculdde de Enfermgem e Obstetríci. UFPel. Pelots, RS, Brsil Correspondence: Mri Aprecid P Rodrigues R. Mrechl Deodoro, 250, 3º piso Pelots, RS, Brsil E-mil: rodriguesmp@terr.com.br Received: 02/11/2008 Revised: 12/05/2008 Approved: 12/17/2008 ABSTRACT OBJECTIVE: To ssess the use of helthcre services by elderly individuls suffering from chronic diseses. METHODS: Cross-sectionl study crried out with 2,889 individuls ged 65 yers or more with chronic conditions rteril hypertension, dibetes mellitus nd mentl illness, living in ctchment res of primry cre units in 41 cities of the South nd Northest regions of Brzil in The nlyzed dt were obtined in the bseline study of Progrm de Expnsão e Consolidção d Súde d Fmíli (Progrm for the Expnsion nd Consolidtion of Fmily Helth). The studied vribles were sex, ge, skin color, mritl sttus, level of schooling, fmily income, smoking, functionl disbility, nd cre model of the primry cre unit. The djusted nlysis of outcomes ws performed by mens of Poisson regression. RESULTS: The prevlence of medicl visit in the lst six months ws 45% in the South region nd 46% in the Northest region. The prevlence of prticiption in groups of eductionl ctivities in the lst yer ws 16% in the South nd 22% in the Northest. In both regions, use of services ws higher for elderly people under the ge of 80 yers, with low level of schooling nd living in ctchment res of primry cre units with Progrm Súde d Fmíli (Fmily Helth Progrm). Only in the South region did the elderly with functionl disbility hve higher prevlence of medicl visits. CONCLUSIONS: The prevlence of medicl visit nd prticiption in groups of eductionl ctivities ws low when compred to previous studies conducted with elderly individuls in Brzil. The results indicte tht, lthough the Fmily Helth Progrm promotes greter use of services t primry cre units by elderly people with chronic conditions, it is necessry to expnd the ccess of those ged over 80 nd of individuls with functionl disbility. DESCRIPTORS: Aged. Helth Services for the Aged. Primry Helth Cre. Helth Services Accessibility. Helth Services Needs nd Demnd. Cross-Sectionl Studies. INTRODUCTION The proportion of elderly individuls in the popultion hs been growing quickly in recent decdes, which implies n increse in the demnd for the helth systems. In developing countries, the impct is bigger due to the gret mount of individuls in conditions of low level of schooling nd poverty, who re more exposed to risk fctors for chronic diseses like smoking, obesity nd sedentriness. In this sense, in 2004 the World Helth Orgniztion (WHO) Socil development nd geing: crisis or opportunity? In: Pnel of the Genev 2000 Forum: the next step in socil development; 2000 June 26-30; Genev. Genev: World Helth Orgniztion, 2000.

2 2 Use of primry cre services by the elderly Rodrigues MAP et l lunched project iming to ttrct the ttention of nd qulify the primry cre professionls concerning the elderly individuls specific needs, highlighting the importnce of sheltering the elderly nd of their prticiption in the decisions regrding their own helth. 17 The Sistem Único de Súde (SUS Brzil s Ntionl Helth System), creted by the 1988 Constitution, gurntees to the Brzilin citizen the eglitrin ccess to the helth services. Since 1994, SUS hs dopted the Progrm Súde d Fmíli (PSF Fmily Helth Progrm) s strtegy to reorgnize primry helthcre, iming to promote better ssistnce nd prevention of diseses in the community. However, the context of the Brzilin municiplities is very diversified, which mkes this process become highly heterogeneous in the ntionl scle. 3 Despite the cretion of the Ntionl Policy for the Elderly s Helth in 1999 nd of the Elderly Sttute in 2003, only in 2006, by mens of the Helth Pct, did SUS begin to consider the elderly popultion s helth s priority. b In primry helthcre, the min objective is now the mintennce of the elderly s functionl cpcity, ensuring priority ssistnce for those identified s frgile. The ssessment of the elderly s helth in two inquiries crried out in Brzil in 1998 nd 2003 showed tht, lthough the poorer individuls present worse helth conditions, they re the ones who lest use the helth services. 10 Considering tht primry helthcre is responsible for the direct provision of the mjority of helth ctions nd progrms, the im of the present study ws to evlute the utiliztion of helthcre services by elderly individuls who suffer from chronic diseses. METHODS This ws cross-sectionl study of dt from individuls ged 65 yers or older, obtined from the bseline study of Projeto de Expnsão e Consolidção d Súde d Fmíli (PROESF - Project for the Expnsion nd Consolidtion of Fmily Helth), crried out in 41 municiplities with more thn 100 thousnd inhbitnts in the period from Mrch to August Of these municiplities, 21 were locted in the South region nd 20 in the Northest region. Smple selection ws performed in multiple stges. Initilly, we clculted the size of the smple tht ws necessry to exmine differences in the effectiveness of the progrms ctions, ccording to the cre model - PSF nd trditionl model -, in the ctchment res of uniddes básics de súde (UBS - primry helthcre units), totling 2,100 individuls in ech geogrphic region, or n overll figure of 4,200 individuls. To increse the representtiveness of the popultion smple nd of the UBS smple (nd to reduce the conglomerte effect), the popultion smple ws locted in pproximtely 10% to 20% of the primry cre network instlled in ech municiplity, reching the figure of 120 UBS in ech region, totl of 240 UBS. Then, the UBS were rndomly selected, bsed on lists mde by the municipl helth deprtments, strtified ccording to the cre model, proportiontely to the size of the municipl primry cre network. Two UBS with PSF model were selected to one UBS with the trditionl model. After dividing the smple of elderly people by the totl of UBS, we estblished tht the smple tht would be interviewed in the ctchment re of ech UBS would be composed of 18 individuls. The individuls were locted by mens of consecutive visits to the households in the ctchment re of the selected UBS. Only one person from the household ws interviewed. The complete methodology of PROESF is described in nother publiction. 6 In the study, 4,003 individuls were identified nd interviewed, nd 2,889 of them suffered from one, two or three chronic helth conditions systemic rteril hypertension, dibetes mellitus nd mentl illness, 1,386 in the South region nd 1,503 in the Northest region. Considering the South region s reference becuse it presented the smllest smple, the mrgin of error for estimting the prevlence of medicl visit in the lst six months ws 1.8% nd for prticiption in groups of eductionl ctivities in the lst yer ws 2.4%. To evlute ssocitions, the study hd n 80% power to detect, s significnt, prevlence rtios of 1.5 or higher, for exposures tht ffect from 10% to 90% of the popultion with 95% level of confidence. The interviews were conducted t the subjects home by 15 previously trined interviewers, using structured nd pre-codified questionnire. In cse the elderly individul ws not ble to nswer the questionnire, nother individul residing in the household could help him if the incpcity ws prtil, or would nswer ll the questions regrding the selected elderly person, if the incpcity ws totl. The dependent vribles were two indictors of use of primry helthcre services. To ech interviewed individul who informed suffering from one of the three chronic conditions mentioned bove, the interviewer sked: Since <six months go> how mny times hve you ttended medicl visit due to <chronic condition> t the <helthcre unit tht serves the re where you live>? nd Since < yer go> hve you prticipted in ny group of <chronic condition> t the <helthcre unit tht serves the re where you live>? Progrm Súde d Fmíli. Rev Sude Public. 2000;34(3):316-9 b Ministério d Súde. Pcto pel Súde Dirio Oficil Unio. 23 fev 2006;Seção 1:46-51.

3 3 We considered s medicl visits t the UBS the nswers of one or more visits due to these chronic conditions, nd the individul who hd ttended medicl visit due to two or more diseses in the lst six months ws not dded more thn once. Individuls with inconsistencies between hving ttended medicl visit nd not reporting ny chronic disese were excluded. We considered s prticiption in eductionl groups in the previous yer the positive nswer of n individul suffering from one or more chronic conditions, nd the individul who hd prticipted in two or three groups in the lst yer ws not dded more thn once. The two outcomes were dichotomous: use of medicl visits in the lst six months (yes/no) nd prticiption in groups of chronic conditions in the lst yer (yes/ no) t the UBS. The independent vribles were demogrphic, socioeconomic, helth hbits, functionl disbility nd UBS cre model indictors. The geogrphic region (ctegorized s South nd Northest) ws demogrphic vrible referring to the context of the smple individuls. The individul demogrphic vribles were sex, skin color (observed by the interviewer nd clssified s white, mixed ethnicity nd blck), mritl sttus (clssified s mrried, with prtner, widow/widower, seprted, divorced nd single) nd ge (in yers). The socioeconomic vribles were level of schooling (complete yers of study) nd fmily income (in Reis). The helth hbit indictor ws smoking (clssified s smoker individul who smoked more thn one cigrette per dy during more thn one month -, ex-smoker nd never smoked). Functionl disbility ws clssified s none, little, medium, much difficulty nd need of someone else s help to ccomplish three or more out of 12 ctivities, nmely: hving shower, eting, getting dressed, going to the toilet, wlking, moving from bed to chir, wshing the fce, pushing lrge object, crrying five kilogrms, crouching down, rising the rms over the hed nd deling with smll objects. The cre model of the UBS ws vrible relted to the helth system nd ws clssified s PSF nd trditionl. The dt were keyborded using the progrm Epi Info 6.04 nd dt nlysis ws performed in the progrm Stt 9.0. Qulity control ws performed by telephone through the ppliction of reduced questionnire, reching pproximtely 6% of the study s smple. The concordnce nlysis ws obtined by the kpp index. The nlyses were strtified by geogrphic region. The comprison between the South nd Northest regions concerning the utiliztion of UBS services ws mde by Person s chi-squre test. The multivrite nlysis of medicl visits nd of prticiption in groups t UBS serving the subjects dwelling res by elderly individuls suffering from chronic conditions ws crried out by mens of Poisson regression with robust vrince, tking into ccount the conglomerte effect. Wld tests of heterogeneity of proportions nd of liner tendency for ordinl vribles were used, with description of prevlence rtios nd respective intervls with 95% confidence. The djusted nlysis of the two outcomes followed conceptul model with four determintion levels. In the first level, the demogrphic nd socioeconomic vribles were considered. In the second level, smoking. In the third level, functionl disbility. In the fourth level, the primry helthcre model of the UBS, trditionl or PSF. To control the confounding fctors, the effect of ech vrible ws controlled for other vribles in the sme nd higher levels with vlue p 0.2 in the ssocition with the outcome. The study ws pproved by the Ethics nd Reserch Committee of Universidde Federl de Pelots. The interviewees received explntions regrding the voluntry chrcter of prticiption in the study, secrecy nd confidentility of individul informtion. RESULTS Tble 1 presents the chrcteristics of the 2,889 interviewed elderly individuls ccording to the studied regions. The elderly of the femle sex, white skin color, widows/widowers nd seprted/divorced/ single, ged up to 74 yers, with up to four yers of schooling, with fmily income up to R$ , with no functionl disbility nd living in ctchment res of UBS with PSF model represented the mjor prt of the smple in both regions. Some chrcteristics of the smple were different between regions. In the South region, the mjority of the elderly hd some level of schooling while in the Northest region the mjority hd never ttended school. In the Northest region, there ws lrger concentrtion in the three rnges of lower fmily income. In the South region, hlf of the elderly hd never smoked while in the Northest the mjority ws composed by the groups of ex-smokers nd current smokers. Tble 2 compres the prevlence of use of the services of the UBS tht serve the subjects dwelling res by elderly individuls with chronic conditions. The prevlence of t lest one medicl visit in the lst six months in the South region ws 44.8% (CI 95%: 42.1;47.5) with design effect of nd 45.6% (CI 95%: 43.0;48.1) in the Northest region with design effect of The prevlence of prticiption in t lest one group of eductionl ctivities in the lst yer ws 16.3% (CI 95%: 14.3;18.2) in the South region with design effect of nd 21.7% (CI 95% 19.6;23.8) in the Northest region with design effect of

4 4 Use of primry cre services by the elderly Rodrigues MAP et l Tble 1. Description of the smple of elderly individuls with chronic diseses living in ctchment res of primry helthcre units. Southern nd Northestern Brzil, (N= 2,889) Vrible South Region Northest Region n % n % Sex Mle Femle Skin color White Mixed-ethnicity Blck Mritl sttus Mrried/with prtner Widow/widower Seprted/divorced/single Age (yers) 65 to to to or older Schooling (yers) to to or more Fmily income (reis) Smoking Never smoked Ex-smoker Smoker Functionl disbility No Yes Cre model of the UBS Trditionl PSF Totl UBS: Primry helthcre unit PSF: Fmily Helth Progrm This vrible presented the mximum number of unknown vlues (88): 52 in the South region nd 36 in the Northest region. Tble 3 presents djusted nlyses of medicl visits t the UBS tht serve the subjects dwelling re in the two studied regions. In the South region, there ws reduction in the use of medicl visits t the UBS fter the ge of 80 yers nd with increse in the level of schooling. The elderly with functionl disbility ttended 30% more medicl visits thn those with no functionl limittions, nd the elderly residing in ctchment res of UBS with PSF model ttended pproximtely 20% more medicl visits thn those residing in ctchment res

5 5 Tble 2. Prevlence of medicl visit nd prticiption in groups of eductionl ctivities t primry helthcre units by elderly individuls with chronic diseses. Southern nd Northestern Brzil, Vrible Totl South Northest p b n % n % n % Medicl visit in the lst 6 months No Yes Prticiption in groups in the lst yer < No Yes The vrible medicl visit t UBS tht serves the subject s dwelling re hd 78 unknown vlues, 46 in the South region nd 32 in the Northest region; the vrible prticiption in groups t UBS tht serves the subject s dwelling re hd 13 unknown vlues, 8 in the South region nd 5 in the Northest region. b p vlue of the chi-squre test for heterogeneity of proportions. of UBS with the trditionl model. In the Northest region, the use of medicl visits in the UBS tht serve the subjects dwelling re decresed fter the ge of 80 yers nd with the increse in the level of schooling of the elderly. The elderly residing in ctchment res of UBS with PSF model ttended pproximtely 60% more medicl visits thn those residing in ctchment res of UBS with the trditionl model. Tble 3. Adjusted nlysis of fctors ssocited with medicl visit t the primry helthcre unit in the lst six months mong elderly individuls with chronic conditions. Southern nd Northestern Brzil, Level Vrible South (n=1332) Northest (n=1479) PR (95% CI) p PR (95% CI) p 1 Age (yers) to to (0.76;1.03) 0.91 (0.79;1.05) 75 to (0.76;1.04) 0.99 (0.86;1.14) 80 or older 0.72 (0.58;0.89) 0.71 (0.59;0.85) Schooling (yers) < to (0.71;0.96) 0.88 (0.76;1.03) 5 to (0.67;0.98) 0.84 (0.70;0.99) 9 or more 0.64 (0.41;0.98) 0.40 (0.22;0.72) Fmily income in quintiles (reis) (0.71;1.10) (0.92;1.26) (0.82;1.14) (0.66;1.01) - 3 Functionl disbility <0.001 b - No 1 - Yes 1.31 (1.15;1.49) 4 Cre model of the UBS b <0.001 b Trditionl 1 1 PSF 1.19 (1.00;1.42) 1.61 (1.33;1.96) PSF: Fmily Helth Progrm Note: Level 2 ws not presented in the tble becuse the vrible smoking did not remin in the finl model; Wld Test for liner tendency; b Wld Test for heterogeneity; PR: Prevlence rtio djusted for vribles in the sme level nd higher tht presented p vlue up to 0.20 in the ssocition with the outcome.

6 6 Use of primry cre services by the elderly Rodrigues MAP et l Tble 4 presents djusted nlyses of the prticiption in groups of eductionl ctivities in the UBS tht serve the subjects dwelling re in the two studied regions. In the South region, the prticiption in groups of eductionl ctivities decresed s the elderly s ge nd fmily income incresed. The elderly who smoked prticipted less in groups of eductionl ctivities thn the ex-smokers. The elderly residing in ctchment res of UBS with PSF model prticipted 2.5 times more in groups of eductionl ctivities thn those residing in ctchment res of UBS with the trditionl model. In the Northest region, the women prticipted pproximtely 30% more in groups of eductionl ctivities. The prticiption in groups decresed s the elderly s ge nd level of schooling incresed. The elderly with functionl disbility prticipted pproximtely 30% less in groups of eductionl ctivities thn those with no functionl disbility. The elderly residing in ctchment res of UBS with PSF model prticipted 2.5 times more in eductionl ctivities thn those residing in ctchment res of UBS with the trditionl model. DISCUSSION The use of helth services is the result of n interction process between fctors relted to the individul, to the helth system nd to the context in which it occurs. 2 The present study observed these three fctors by nlyzing individul vribles together with the vrible referring to the cre model of the UBS strtified by geogrphic Tble 4. Adjusted nlysis of fctors ssocited with prticiption in groups of eductionl ctivities t primry helthcre units in the lst yer mong elderly individuls with chronic conditions. Southern nd Northestern Brzil, Level Vrible South Northest PR (95% CI) p PR (95% CI) p 1 Sex Mle - 1 Femle 1.27 (1.01;1.58) Age (yers) b <0.001 b 65 to to (0.67;1.20) 0.89 (0.70;1.14) 75 to (0.61;1.12) 0.86 (0.67;1.11) 80 or older 0.58 (0.39;0.87) 0.43 (0.31;0.61) Schooling (yers) <0.001 b to (0.60;0.97) 5 to (0.42;0.95) 9 or more (0.10;0.71) Fmily income (reis) b (0.71;1.53) (0.73;1.37) (0.62;1.09) (0.40;0.93) - 2 Smoking Never smoked 1 1 Ex-smoker 1.04 (0.81;1.35) 1.09 (0.89;1.33) Smoker 0.56 (0.34;0.92) 0.69 (0.47;1.02) 3 Functionl disbility No - 1 Yes 0.67 (0.53;0.84) 4 Cre model of the UBS <0.001 <0.001 Trditionl 1 1 PSF 2.46 (1.58;3.82) 2.53 (1.55;4.13) Wld Test for heterogeneity b Wld Test for liner tendency

7 7 region. The ssessment of elderly individuls with chronic helth conditions imed to reduce the use of services disconnected from the need of helthcre. Mking comprison with dt referring to elderly individuls obtined from the demogrphic census of 2000, it is possible to observe ctegories ssocited with greter use of helth services: women, individuls older thn 75 yers nd individuls with low level of schooling. 13 Smoking ws more frequent mong elderly people in the Northest region, result tht ws lso observed in domiciliry inquiry tht ws crried out in 2002 nd 2003 in 15 Brzilin cpitls nd in the Federl District. In this sme inquiry, n ssocition ws identified between lower level of schooling nd smoking, which justifies the presence of lrger proportion of smokers in the smple of the Northest region. The PSF model ws more frequent in the Northest region thn in the South one, which is in greement with the Ministry of Helth s policy on implementing the PSF strtegy first in the UBSs of tht region, due to the greter shortge of helth services nd worse indexes of popultion morbidity nd mortlity. b As for medicl visits, in the Pesquis Ncionl por Amostr de Domicílios (PNAD - Ntionl Survey through Households Smple) of 1998 nd 2003, the reserchers identified 72% nd 78%, respectively, of prevlence of ttendnce to t lest one medicl visit in the lst 12 months by individuls ged 60 yers or older. 11 A popultion-bsed study crried out in the city of São Pulo identified 83% of this sme outcome in individuls ged 60 yers or older in the lst 12 months. 12 As the smple of the present study included elderly individuls ged 65 yers or older who referred suffering from chronic diseses, it ws expected tht pproximtely hlf of them hd ttended t lest one medicl visit in the UBS tht serves their dwelling re, even if we consider tht the recll period tht ws used corresponded to hlf of those studies. The prevlence of medicl visit ws similr in both regions, which is in greement with the evlution of the dt from the 2003 PNAD, which observed tht the utiliztion of the SUS services ws similr cross geogrphic regions, fter djusting for income nd level of schooling. 14 The reduction in medicl visits in the UBS tht serve the subjects dwelling re ccording to the increse in the elderly s ge, minly for those ged 80 yers nd more, in both regions, ws lso observed in study tht evluted the generl use of helth services by the elderly. 12 Considering tht the prevlence of chronic diseses increses with the increse in ge, 1 it is probble tht these individuls present difficulties regrding the ccessibility to the UBS. The reduction in medicl visits in the UBS tht serve the subjects dwelling re in both regions ccording to the increse in the level of schooling suggests tht, s observed in other studies, the individuls with higher level of schooling serch for other helth ssistnce plces. 5,14 The higher prevlence of medicl visits in elderly individuls with functionl disbility only in the South region suggests tht in the Northest region the elderly hve less ccess to the UBS. Considering tht this condition is n indictor of helthcre need, 7,13 this result indictes the importnce of creting strtegies tht ensure these individuls ccess to medicl ssistnce in primry cre. The higher prevlence of medicl visits in the UBS tht serve the subjects dwelling re mong elderly people residing in res of UBS with PSF strtegy in the South nd Northest regions indictes tht this cre model promotes higher ccess of the elderly. A study tht compred the use of services of UBS with PSF model nd with the trditionl model in São Pulo showed tht PSF hs promoted more equitble use of the primry helth services. 8 The evlution of preventive ctivities trgeted t the elderly in primry cre is scrce in the literture. The prevlence of prticiption in t lest one group of eductionl ctivities for individuls with chronic conditions, lthough low in both geogrphic regions, ws worse in the South. This difference is justified by the lower proportion of UBS with PSF model in the South, since these ctivities re more offered t the UBS tht hve this model of cre. b A review study showed tht vribles relted to helth conditions ply less importnt role in the determintion of use of preventive services compred to use of helth ssistnce services. 4 The greter prticiption of elderly individuls in groups of eductionl ctivities in the Northest region my be relted to the worse socioeconomic condition of the elderly in tht region, which mkes them become more dependent on the services provided by the UBS, like the mediction provision of the progrms of rteril hypertension nd dibetes, gurnteed to users who prticipte in the ctivities of groups of people suffering from these diseses. The greter prticiption of elderly women in groups of eductionl ctivities, observed in the Northest, is justified by the higher vlue the elderly women ttribute to these ctivities. 7 The lower prticiption in groups of eductionl ctivities ccording to the elderly s increse in ge in both regions my be ttributed to the higher prevlence of Ministério d Súde, Instituto Ncionl do Câncer, Coordenção de Prevenção e Vigilânci. Prevlênci de tbgismo no Brsil. Rio de Jneiro; b Progrm Súde d Fmíli. Rev Sude Public. 2000;34(3):316-9.

8 8 Use of primry cre services by the elderly Rodrigues MAP et l chronic diseses mong the oldest individuls, 1 which hmpers the ccess to the UBS. The lower prticiption of elderly individuls with higher fmily income in groups of eductionl ctivities in the South region is justified by the preference for using privte helth services. 5 The greter prticiption of the elderly who re ex-smokers in groups of eductionl ctivities is due to the higher prevlence of chronic diseses in these individuls. 15 The lower prticiption in groups of eductionl ctivities of elderly people with functionl disbility in the Northest region indictes tht these individuls hve less ccess to the UBS tht serve their dwelling re thn those who do not hve functionl limittions. 16 The greter prticiption in groups of eductionl ctivities of elderly individuls residing in ctchment res of UBS with PSF model in the South nd Northest regions shows tht PSF promotes greter ccess to the UBS of elderly individuls with chronic helth conditions when compred to the trditionl model. 8 Among the limittions of the present study, the crosssectionl design my hve cused reverse cuslity bis. However, the use of the recll form imed to minimize the potentil effect of this bis. The resolution degree of the services provided by the UBS tht serve the subjects dwelling re ws not evluted, lthough it is importnt for the continuous use of the helth services. On the other hnd, the low percentge of losses in reltion to the smple estimted for elderly people reinforces the study s internl vlidity. The smple cn be considered representtive of the elderly who suffer from one or more of three chronic conditions rteril hypertension, dibetes mellitus nd mentl illness who reside in ctchment res of UBS of municiplities with more thn 100,000 inhbitnts in the South nd Northest regions of Brzil. In conclusion, the results of the present study showed tht primry cre ssisted more the elderly with lower level of schooling nd fmily income, contributing to the promotion of higher equity in helth. However, the proportion of t lest one medicl visit in the lst six months ws lower thn expected when compred to the prevlence in popultion dt. The greter utiliztion of UBS with PSF model indictes tht this primry cre strtegy, independently of the geogrphic context, promotes higher ccess of the elderly who suffer from chronic conditions thn the trditionl model. The elderly ged over 80 yers, s well s those who hve functionl disbility, must benefit from strtegies tht ensure the ccess to the UBS.

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